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� <br /> � ^� 2 D <br /> W � � fl fl 2 � Y � o -�i � <br /> r = D p � �n � a G� t'n <br /> O (� 7�, N c-m� I�.. � '� O � Cti <br /> 7� s �`� <br /> 7 � �,�.� � o -*� c� Q. <br />� � � - �'' M, T' z ►-` � <br /> r^ c� `�,,� s m y <br /> Z -_ 11� rn � � r � � � <br /> � (� c� � � r n oo v, <br />�� �- u' ,s c.� � -.a � <br /> {/'� 1 <br />�'C1 �. ,� �'' CJl � l..', W � <br />� � � # � � � � <br />� � � <br /> 7 <br /> --�-- __. �.�� <br /> WHEN TI�S COPY CARI�S fl�RAISED SEAL OF THE NEBRASKA HEALTH ES <br /> SYSTEIY�IT CERTIF/ES TFIF BELOW TO BE A TRUE COPY OF THE ORI(iINAI�,=,'���dy/T/�l <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STA��t��'�Ol���l�J�#/IS <br /> THE LEOAL DEPOS/TORY FOR VITAL RECORDS - _- <br /> oA�oF,ss�A� 9g-�os�s� .- _ - �'��� <br /> SEP 1 6 1998 A�r,�rsr�, i� o -��-- <br /> UNCOLN,NEBRASKA HEALTH AND�1llA '` YS#�hl <br /> -_- �- •-==-�-�-�_ - <br /> STATE OF NEBRASKA-DEPARTMENT OF HEAL'I�i AND HUMAN SEA1�,9-�$f�1VEE'XIi8t�U1!�RT <br /> VITALSTAT[S1iCS " -� -- -- <br /> CERTIFICATE OF DEATH '--=_-- <br /> 1.DECEOENT•NAME FIRST MIOOLE . LAST 2.SE% 3.DATE OF DEATM lMqrM.Day.YW/ <br /> Mary Evelyn Lindsa Female Se tember 5, 1998 <br /> 1.CITV AND STATE OF BIRTH /pnpl h U.SA.Mm�Camby! Ss.�AGE-Wt&NWay UNOER 1 VEAR UNDER 1 DAV 6.DATE OF BIRTM /MdNh.D�y.YNi) <br /> ' Ra an, Nebraska "'"' 76 � Mos. o��s x.HOUAS� �NS October 15, 1921 <br /> I 7.SOCIAI SECURTIV NUMBER B�.PI.ACE OF DEATH <br /> 5 0 7-16-7 7 3 3 MIOSPITAI: � InpedsM OTHER: � Nursinq Fbm6 <br /> Bb.FACIUTV.Nams /AndirufihRion,yiwsMNandnumbrrl -- � EROulatieM � RnMSnca <br /> Saint Francis Medical Center ❑ D0A ❑ °"°����y� <br /> &.CITY.TOWN OR LOCATION OF DEATH . 8tl.INSIDE CITV UMITS Bs.CWNTY Of DEATH <br /> Grand Island �« � � ❑ Hall <br /> 9a RESIDENCE-STATE 9b.COUNTV 9t.CITY.TOWN OR IOCATION . . __�. . 8d.SiREET AND NUMBER /Meh�cMpZp Co�8�0'3 9e.INSI�pTV LIMITS <br /> Nebraska Hall Grand Island 430 Eisenhower Dr. �«� �w❑ <br /> 10.RACE•(�.p.WMN.Bluk:MNriCM NdM. 11.ANCESTRV Il.q..NaN�n.MsxiCN.OMMn,Mcl �2.�MAFRIED O WIDOWEO t 3.NAME OF SPOUSE /p wiAr.piN m�1aW��) <br /> "`��SP°`�"� White 1SP"�'� American NE�ER DiVOACED Winston P. Lindsay <br /> 1N.USUAL OCCUPATION IGrve kMdd wwk aWN dvinp moaf 1�D.KIND OF BUSINESS INDUSTRV 15.EDUCATION �Spscih/onN h WW��om0�Mb) <br /> d workmg b'h,rwn ArMrMI � ENmernary a Saeontl�ry 10-t21 It•<a 5•i <br /> Homemaker pomestic �ears <br /> 18.FATMEH-NAME FIRST MIODIE LAST 17.MOTHEH FIRST . MIDDLE MAIDEN SURNAME <br /> Raymond NMN Shumard Katie NMN Black <br /> 18.WAS DECEASED EVEF IN U.S.ARMED FOHCES? 19s.INFORMANT-NAME <br /> Ives.no.or unk.� pl yes.g�ve war aM Oabs ol servicasi � <br /> No ------- WinSton P. Lindsay <br /> 19G.INFORIJ4NT MAILING ADDRESS ISTREET OR R.F.D.NO..GTV OR TOWN.STATE.21P) . � <br /> 430 Eisenhower Dr. , Grand IsTand, Ne. 68803 <br /> 20. BALMER•S�GNATURE 8 LICENSE NO. � 21a.METHOD OF q$POSITION 21b.DATE 21a CEMETERV OR CREMATORr�NAME <br /> �. �/'Q'3 �]e� ❑�.��e� Se t. 8, 1998 Westlawn Memorial Park <br /> 22a.FUNEML NOME-NAME 21C.CEMETERV OR CREMATORV LOCATION GTV Oq TONM SUTE <br /> Livingston-Sondermann F.H. �°nin1qn �°ona�' Grand Island, Nebraska <br /> 22b.fUNERAI HOME AODRESS ISTREET OR Rf.D.NO..CITV OR TOWN.STATE,21P� <br /> 601 N. Webb Road, Grand Island, Ne. 68803-4050 <br /> 23. IMMEDIATE CAUSE IENTER ONLV ONE CAUSE PER LINE FOR ial.lb�.AND(c�� � InNrvd Oslwsm pqN and daa�h <br /> �PAFT //�/� �(`/- -7-- Tf Jp I � Q Q <br /> � lal l..r-V 1 V ✓)�..,�� J � V 1i ����� J ��! L� ('� V �� � F-�-� <br /> DUE 70.OR AS A CONSEOUENCE OF. I IMSrval Eelw�sn omst sn0 Oeam <br /> 2 L l,y-US � <br /> ,b, �D i►��''��'S NL L L , <br /> WE TO.OR AS A CONSEWENCE OF: ' � � MiMn'N bMws�OMM md 0ltlh <br /> � <br /> I <br /> �C� I <br /> OTHER SIGNIFICANT CONDITIONS-COndifOn�COntriOutlnp b Me AsaM but nd rMa�eE . PART III�f FEMALE.WAS THERE A 2� AUTOPSY 25.WAS CASE HEFERRED TO MEDICAL <br /> PART . PREGNANCY IN THE PAST 3 MONTHS? � EXAMINEF OR CORONER� <br /> II <br /> (Ages t0-Sa� Vss No Ves No, � Vss No <br /> 26a. 26A.DATE Of INJURV (MO.Day.Yc) 26t.HOUF OF IWUHV 260.DESCRIBE HOW INJURV OCCURRED <br /> � Atci�nl � Untlelermingd M . <br /> � Suicitle � Pnntlmg 26e.INJURY AT WOAK 26f.�PU�C�OF.nINgd�RY%At hortig,fa�m.sireet.factay 26g.LOCATION STREE7 OR fi.F.D.NO. CITV OA TOWN STATE <br /> ❑ ❑ ❑ Ifi �b SPecnl% <br /> NomicMe Invesvgatw� Yes No <br /> 27a.DATE OF DEATH /MO.Oay n.� 28a.DATE SIGNED lMO Oay.YrJ � 2Bb.TIME OF DEATN <br /> X C � <br /> b5 ' 7 ' � . . E�� . M <br /> ��i 27b.DATE SIONED (MO..D�y.Ytl 27C.TIME OF DEATH ��� 28c.PRONOUNCED DEAD lMO..Day.Yc/ 28d.PRONWNCED OEAD /Hcuq <br /> t X y �/ /, »< <br /> s� _ ,_ i'O ^ I 7 M g �� ..- M <br /> r� 27tl.701M Wq d my knowN�fqa. th occurretl q IM' ,dns and due tlUe to IM 2Bs.O�+ihs Gait d�xaminatiai�M�p InWStiq�GdL in my oqnqn 0sath OCCUrrW tl <br /> N fqa a <br /> Ve�welel euad. � a Me tlme,dW uM Wace�nd Eve b IM c�uaNs)�Md. <br /> i� <br /> (S-n�turo�nC Titla � tlw�and Titls <br /> 29.DIO TOBACCO USE CONTRIBU THE DEATM4 , 30.a HAS ORf3AN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT OMNTED? <br /> k VES � NO � UNKNOWN � � YES NO � VES� � NO <br /> 31.NAME AND ADDRESS OF CERTIFIEfi(PHVSICUIN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY� T q nnl) <br /> �^ k.� ` / Sk� ,�G D �r 1��Q�rd L- � '��. <br /> 32a REOISTRAR . 32b.DATE ILED BV REOISTMR (�b..Day.Yr.� <br /> ' SEP 15 �98 <br />